Copyright Statement

Abstract

Rationale, aims and objective Accrediting health care organizations against standards is
a recognized safety and quality intervention. The credibility of an accreditation programme
relies on surveying reliability. We investigated accreditation survey coordinators’ perceptions
of reliability issues and their continued relevancy, during a period of national accreditation
reform.
Method In 2013 and 2014, questionnaire surveys were developed using survey coordinators’
feedback of their experiences and concerns regarding the accreditation process. Each
year, a purpose-designed questionnaire survey was administered during the accrediting
agency survey coordinator training days.
Results Participants reported that survey reliability was informed by five categories of
issues: the management of the accreditation process, including standards and health care
organizational issues; surveyor workforce management; survey coordinator role; survey
team; and individual surveyors. A new accreditation system and programme did not alter
the factors reported to shape survey reliability. However, across the reform period, there
was a noted change within each category of the specific issues that were of concern.
Furthermore, consensus between coordinators that existed in 2013 appears to have diminished
in 2014. Across all categories, in 2014 there was greater diversity of opinion than in
2013.
Conclusions The known challenges to the reliability of an accreditation programme
retained their potency and relevancy during a period of reform. The diversity of opinion
identified across the coordinator workforce could potentially place the credibility and
reliability of the new scheme at risk. The study highlights that reliability of an accreditation
scheme is an ongoing achievement, not a one-off attainment.